1. Vesna Kesić Institute of Obstetrics and Gynecology Clinical Center of Serbia EASO Masterclass in Clinical Oncology 27-29. October, 2011, Amman, Jordan Cervical Cancer - State of Art -
2. It has been estimated that approximately 500 000 women develop cervical cancer every year, and 260 000 women die of the disease. WHO, 2009
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4. Life-time risk (%) for cervical cancer USA 0,83 Scandinavia 1,01 India 2,22 South Amerika 5,31 5.8 West Asia 7.4 East Asia 7.4 Australia/N. Zeal. 7.7 North America 9.0 North Europe 10.0 West Europe 10.7 South Europe 12.1 North Africa 14.5 East Europe 18.7 South East Asia 26.2 South Cent. Asia 28.0 Central Africa 28.6 South America 29.3 West Africa 30.6 Central. America 38.2 South Africa 42.7 East Africa
5. Incidence of Cervical Cancer per 100,000 Females in Arab World < 4.0 4.0 – 7.9 8.0 – 11.9 12.0 – 15.9 ≥ 16.0 Algeria Map produced by Prof. Inas Elattar Pakistan Pakistan Morocco Afghanistan Palestine Bahrain Iran Iraq Sudan Somalia Libya Egypt Saudi Arabia Oman Yemen UAE Jordan Qatar Kuwait Syria Lebanon Djibouti
6. Two key reasons : 1. The vast majority of women still know little about cervical cancer or what they should do to prevent it. 2. Many countries have ineffective prevention programmes or no prevention programmes at all.
7. As the consequence, a high proportion of cervical cancer is diagnosed when already advanced and metastatic, leading to low probability of cure and high mortality rates . 85% Cervical Cancer: Groote Schuur Hospital, 1984 – 2000 (n = 3098)
16. HPV infe c tion Low-grade changes High-grade lesions Cancer 300 milion s 30 milion s 10 milion s 0. 5 milion s HPV E6, E7 Cellular changes Many years 8-15 HPV infe ction Parkin DM, Bray F, Ferlay J, Pisani P. CA Cancer J Clin. 2005;55:74–108 World Health Organization. Geneva, Switzerland: World Health Organization; 1999:1–22. Number of cases 0.15% ! Estimated World Burden of HPV-related Disease and Diagnoses
18. Natural history of cervical cancer and prevention Precancerous lesion Invasive disease Normal Cervix Persistent infection with HR types HPV Clearance Progression Initial HPV infection
33. Most patients with early stage cervical cancer are treated by either radical surgery or radical radiotherapy. Both treatment modalities have proven to be equally effective . Landoni et al : Lancet 1997 350 535- 540
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38. Modern approach to the surgical management of cervical cancer Conservative Radical for early disease for advanced disease Tailored
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42. x The diagnosis of stage Ia cervical cancer should be based on conization !
43. If distant spread is very unlikely, simple but complete excision of the lesion suffices. If it is likely that the cancer has spread, than an extended operation should be performed.
44. Depth of invasion LVSI Risk of node metastases 0-3 - < 1 / 1000 0-3 + 2 / 100 3-5 - 2/ 100 3-5 + 5 / 100 Stage Ia cervical cancer
53. T y p e II I T ype II Types of hysterectomy- Piver 40% Magrina, 1995 0.8% Urinary dysfunction 7% 1.1% Thromboembolism 0.3% 0.5% Deaths 1% 0.3% Digestive fistulas 4.8% 0.3% Urinary fistulas Type III Type II Complication
62. Adjuvant therapy in early cervical cancer For adjuvant irradiation - High risk, negative nodes - Positive nodes (1-3) - Poorly differentiated or undiferentiated tumor (G3) - LVSI (lympho-vascular space invasion) - Primary tumor > 3cm (tumor-cervix volume > 3cm ) - Endocervical invasion (barrel shaped ) - Inadequate surgery - Insufficient HP report For adjuvant chemo-irradiation - Positive resection margins - Involvement of parametria - Residual tumor
63. Postoperative pelvic radiation in patients with nodal metastases has been the standard approach. It increases local control, but not the overall survival , due to inability of adjuvant pelvic irradiation to influence distant metastases
67. The survival of patients that had bulky nodes removed has been significantly improved compared to those who had not the nodes resected (31% vs 6%) Hacker et al. Int. J Gynecol Cancer, 1995;5: 250-256 1. KiKim et al. Gynecol Oncol, 1998; 69: 243-7
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69. Extended-field radiotherapy is the standard part of treatment achieving the long-term survival of 30-40% for stage Ib patients with positive PALN. Consistent benefit of concurrent chemo-radiation with Cis-platin based chemotrerapy incorporated in extended-field irradiation.
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71. Neo-adjuvant chemotherapy followed by radical surgery has emerged as a possible alternative to conventional chemo-radiation, which may improve a survival in patients with stage Ib2 disease Benedetti -Panici P.J Clin Oncol, 2002; 20: 179-188 Tierney J. Eur J Cancer, 2003; 39: 2470-2486 14%
80. The incidence of cervical cancer in one country is an indicator of how much the whole society takes care about its women.
Notes de l'éditeur
Prevention is not a new invention. It took a long way, 4000 years way, from old Egypt to Zur Hausen who identified HPV virus and got Nobel Prize, to realize
This is when precancer develops and which will eventually progress to CC
In two words…
This means that there must be something to modify the course of HPV - Immune response